Carers Application Form

Please complete all the information on this form and press the submit button at the end. We will contact you in due course.

If you would prefer, please download our pdf version and complete and return to us by post.

Section 1 - Personal Details

• Position Applied For: Live-InLive-Out
• Surname
• Forename(s)
• Title Mr Mrs Miss Ms
• Address
• Telephone
• Mobile
• Email
• Which languages do you speak?
• How did you hear about Draycott Nursing?

Section 2 - History

• Please summarise any specialist areas of nursing or care, eg. Dementia, Palliative Care
• Which of the following mandatory training days have you attended?
• Manual Handling
• First Aid
• Food Hygiene

Section 3 - Education and Qualifications

• Please provide details of your school leaving qualifications (include dates and names of establishments)
• Please provide details of any additional qualifications

Section 4 - Employment History

• Current/Last employer
• Job Title
• From (date)
• To (date)
• Summary of role and responsibilities
• Reason for leaving this position

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• Previous employer
• Job Title
• From (date)
• To (date)
• Summary of role and responsibilities
• Reason for leaving this position

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• Previous employer
• Job Title
• From (date)
• To (date)
• Summary of role and responsibilities
• Reason for leaving this position

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• Previous employer
• Job Title
• From (date)
• To (date)
• Summary of role and responsibilities
• Reason for leaving this position

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• Previous employer
• Job Title
• From (date)
• To (date)
• Summary of role and responsibilities
• Reason for leaving this position

Section 5 - References

Please provide details of 3 professional referees who ideally have knowledge of your work as a nurse or carer. Referees must be in a managerial or a senior position and not colleagues, friends or relatives.If your referees are outside the UK then please provide a professional email address.

• Referee 1 Name
• Referee Job Title
• Company Name and Address
• Postcode
• Telephone
• Fax
• Email
• Your Job Title

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• Referee 2 Name
• Referee Job Title
• Company Name and Address
• Postcode
• Telephone
• Fax
• Email
• Your Job Title

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• Referee 3 Name
• Referee Job Title
• Company Name and Address
• Postcode
• Telephone
• Fax
• Email
• Your Job Title

Section 6 - Passport and Driving Licence Details

If you have a non EU passport please provide details of your eligibility to work in the UK

• Work Permit Type (eg.student, indefinite leave)
• Expiry Date
• Do you hold a valid UK driving licence? YesNo
• Expiry Date

Section 7 - Criminal Records

This position is exempt from the provisions of the Rehabilitation of Offenders Act 1974. You are therefore not entitled to withhold information requested by the Company about any previous convictions in this country or abroad which you may have, even if in other circumstances these would be regarded as 'spent'.

• Do you have any criminal convictions in the UK or abroad? YesNo
• Have you ever been barred from working with vulnerable adults or children? YesNo
• If your answer is yes to either of the above questions, please provide details
• Have you had a criminal records check? YesNo
• Date

Section 8 - Next of Kin

Please provide details of your next of kin

• Name
• Relationship to you
• Address
• Telephone No
• Mobile

Other emergency contact

• Name
• Relationship to you
• Address
• Telephone No
• Mobile

Section 9 - Confirmation

By submitting this application form, you agree to the following statements:

I confirm that the information I have given is true. I understand that if information given on the application form is found to be false it may result in disciplinary action which could include dismissal.

I understand that any personal information stored by Draycott Nursing, may be accessed from time to time by authorised inspectors from the Care Quality Commission (CQC). I give permission for these individuals to have access to my records.